3 Dual Diagnosis Resource Needs in Spain 85 Various factors may contribute to the particularly strong association between lifetime diagnoses of addictive disorders and other mental disorders. This relationship is complex, since these concurrent disorders share common brain substrates and factors (Volkow, 2001). The high prevalence of dual pathology (above 50%) has been well documented in clinical and epidemiological studies (Regier et al., 1990; Kessler et al., 1996; Weaver et al., 2003; Kessler, 2004; Adamson, Todd, Sellman, Huriwai, & Porter, 2006; Rush & Koegl, 2008; Swendsen et al., 2010; Pulay et al., 2010; Roncero, Fuste et al., 2011; Hasin et al., 2011; Szerman et al., 2012; Szerman et al., 2013). Four major epidemiological surveys have examined the co-occurrence of substance use disorders and other psychiatric disorders in the United States (the Epidemiological Catchment Area study or ECA, Regier et al., 1990; the National Comorbidity Survey or NCS, Kessler et al., 1994; Kessler et al., 1996; the National Comorbidity Survey Replication or NCS-R, Kessler, Chiu, Demler, Merikangas, & Walters, 2005; Gadermann, Alonso, Vilagut, Zaslavsky, & Kessler, 2012; and the National Epidemiological Survey on Alcohol and Related Conditions or NESARC, Lev-Ran, Imtiaz, Rehm, & Le Foll, 2013). These different epidemiological studies coincide in suggesting a reciprocal contribution to the development of the other disorder in dual diagnosis (Kessler, 2004; Compton, Conway, Stinson, Colliver,& Grant, 2005; Volkow, 2007). A strong association between lifetime diagnosis of any mental illness and rates of transition from mere substance use to a substance use disorder also exists (Lev-Ran et al., 2013). Provision of services for patients with dual pathology currently represents an important challenge. Failure to detect and adequately treat co-occurring syndromes can jeopardize a patient s chances of success (Kessler et al., 1994). In addition to the shortage of specialist treatment resources for patients with dual diagnosis, in many countries there is duplicity of services for addiction and mental health disorders (Weaver et al., 2003; Baldacchino, 2007). Traditionally, mental health and substance abuse services have been provided sequentially or in parallel. This commonly resulted in low adherence of patients with dual disorders to both treatment resources and an inadequate management of the common interrelated problems of the comorbidity (Farren, Hill, & Weiss, 2012; Pettinati, O Brien, & Dundon, 2013). In this context, a number of strategies have been implemented to combine and/or integrate mental health and addiction treatment resources (Torrens, 2008; Hawkins, 2009; Farren et al., 2012). Several reports have identified different psychosocial and pharmacological treatments for these patients (Brunette & Mueser, 2006; Torrens, 2008; Hawkins, 2009; Thylstrup & Johansen, 2009; Pettinati et al., 2013; Martinez-Raga, Knecht, de Alvaro, Szerman, & Ruiz, 2013), and only recently have clinical guidelines been issued to integrate both treatment approaches (Hintz & Mann, 2006; Zaleski et al., 2006; Lingford-Hughes, Welch, Peters, Nutt, & British Association for Psychopharmacology, Expert Reviewers Group, 2012). The perceptions of professionals may be an important factor in the improvement of patients mental health and substance use treatment (Olivares et al., 2013). Recent studies also highlight the importance of professionals perceptions on the current management of patients with dual diagnosis, such as the perception that dual pathology is usually severe and that treatment adherence influences outcome (Roncero et al., 2013). Although specific resources are currently being created for patients with dual pathology in Spain (such as inpatient and outpatient units, or day centers), few studies have assessed the implementation of these strategies for patients with dual diagnosis, particularly those based on professional opinion. This national survey was conducted to assess professionals perceptions and knowledge of the current state of the implementation of specific resources for patients with dual pathology in Spain, based on an online survey of the health care professionals involved. The results obtained should help raise awareness of the need to implement specific strategies for the management of patients with dual pathology. METHODS Between February and May 2011, we conducted a national survey of 659 health care professionals treating dual pathology in patients in various treatment settings throughout Spain in order to explore their perception of the available health care resources and the needs of patients with dual pathology. A group of experts in dual diagnosis from different clinical and academic origins designed a questionnaire specifically for this study (available on The questionnaire included information on the professional background of the participant (location, academic and specialist degree, research society and treatment network to which they were attached), percentage of patients with dual pathology seen in their units, current available resources for dual pathology (such as outpatient units, inpatient units, day centers, occupational and vocational rehabilitation programs or therapeutic communities) and resources that, in their opinion, should be made available for patients with dual disorders. Their opinion on the integrated model was also solicited. All the members of the Spanish Society of Dual Disorders scientific association (Sociedad Española de Patología Dual) and the professionals in the society s database (more than 2,000) were sent an inviting them to complete the questionnaire. To reach the greatest possible number of participants, the message was sent three times. Moreover, the questionnaire was available to all the professionals working in the mental health or addiction field in Spain who accessed the Spanish Society of Dual Disorders website. The study and procedures, approved by the Ethics Committee of Hospital de la Vall d Hebrón (Barcelona, Spain), complied with the ethical standards laid down in the Helsinki 2014, Volume 10, Number 2

4 86 N. Szerman et al. Declaration, as revised in After reading a complete explanation of the study, professionals consented to participate voluntarily without receiving any remuneration by completing the survey. Those who did not wish to consent simply exited without completing the survey. In the statistical analysis, frequency tables and percentages were obtained for categorical variables while measures of central tendency and dispersion were calculated for continuous variables (mean, standard deviation, and range). RESULTS A total of 659 professionals across Spain working with patients with dual pathology participated in the study. The majority were of Spanish origin (n = 625), while others were from Latin America (n = 22), other European countries (n = 8), or a small number of other places (n = 4). The sample included 362 women (54.9%) and professionals from 553 centers and 235 cities across Spain. Respondents were not concentrated in any one area or center, so representation was fairly distributed (95.9% of centers provided only one or two participants). Most of the participants were psychologists (43.40%) and psychiatrists (32.93%), followed by general practitioners (14.57%) and physicians with other specialist degrees (7.59%), while a small percentage of professionals had two or more specialties (See Table 1). Participants did not always respond to every survey item, and this is indicated whenever the sample size is not the full 659. A total of 93.2% of responding study participants (n = 592/635) reported that specific resources for dual pathology were necessary, with similar percentages for the various subgroups of participants based on their network affiliation. Among the resources identified as necessary, 76.7% of respondents (n = 487/635) preferred intermediate resources, TABLE 1 Characteristics of Survey Respondents (N = 659) Characteristic n (%) Gender Female 362 (54.9%) Male 297 (45.1%) Country of Origin Spain 625 (94.8%) Latin American 22 (3.3%) Other European 8 (1.2%) Other 4 (0.6%) Specialty Area Psychologist 286 (43.3%) Psychiatrist 217 (32.9%) General Physician 96 (14.6%) Other Physician 50 (7.6) Dual Specialties 10 (1.5%) followed by 68.8% (n = 437/635) indicating acute detoxification units and 64.6% (n = 410/635) indicating medium-stay rehabilitation units. According to 54.0% of respondents (n = 343/635), integration exists between mental health and addiction networks, and 49.6% of them (n = 170/343) considered integration to be very good or good. Overall, 65.2% of participants (n = 414/635) reported that the specific resources available for dual pathology were public, while 39.1% (n = 248/635) said resources were semiprivate and 27.6% (n = 175/635) said available resources were completely private. About half of the participants were partially aware of the available resources (n = 340/635, 53.5%), while 29.6% (n = 188/635) of the sample reported being fully aware of them. Professionals working in these specific resources for patients with dual diagnosis included general practitioners, psychiatrists, psychologists, nurses, and social workers. Across all three kinds of resources (mental health, addiction, and integrated), staff turnover was quite high. Less than half of respondents indicated low turnover (n = 291/605, 48.1%), while 39.3% (n = 238/605) reported occasional turnover and 12.6% (n = 76/605) indicated frequent employee turnover. The highest level of employee changes or turnover occurred in the mental health resources. More than a half of participants (n = 340/605, 56.2%) considered that access of patients to the individual resources was direct, while 43.8% (n = 265/605) considered that patients acceded to resources for dual pathology through other resources. Overall, 26.8% of respondents (n = 162/605) reported that there were outpatient programs for dual pathology, while 30.4% (n = 184/605) stated there were specific hospitalization units (Figure 1). Conversely, 62.5% of participants (n = 378/605) reported a greater availability of detoxification units accepting patients with dual disorders, with relevant differences depending on the area (76.4% in drug addiction and 47.7% in mental health). Approximately half of the participants (n = 286/605, 47.3%), stated that psychiatric acute admission units were available for patients with dual diagnosis. Subacute inpatient units (1- to 3-month stays) for patients with dual pathology were less common (reported by 16.9% of participants, n = 99/587, each participant reported the existence of a mean of 1.04 ± 1.54 units in his/her area). Approximately a third of participants (n = 201/587, 34.2%) stated that outpatient intermediate resources were available, with a mean of 1.60 ± 2.74 units considered available per surveyed professional in his/her area. The existence of a day hospital for patients with dual pathology was reported by 15.5% (n = 91/587) of respondents (with a mean of 0.69 ± 1.28 hospitals per surveyed professional), while day centers for dual pathology were reported by 21.5% of respondents (n = 126/587), with a mean of 0.75 ± 1.22 centers per surveyed professional. Only 11.6% of participants reported availability of specific vocational programs (n = 68/587, with a mean of 1.59 ± 7.27 programs considered available per participant in her/his Journal of Dual Diagnosis

5 Dual Diagnosis Resource Needs in Spain % 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Outpa ent programs for pa ents with dual pathology 43.8% Drug addic on 16.0% Mental health 30.9% 3.1% 10.5% Other Unknown No answer FIGURE 1 Outpatient programs for patients with dual pathology. (Color figure available online). area) and the number of respondents who had knowledge of occupational rehabilitation centers (n = 98/587, 16.7%, mean of 0.70 ± 1.44 units/professional/area) was also low. Participants who reported therapeutic communities accepting patients with dual disorders was higher (n = 246/587, 41.9%, mean of 0.88 ± 1.01 units/professional/area). In the opinion of three-quarters or more of the surveyed professionals, there were four types of resources most needed for patients with dual pathology. Eighty-nine percent (n = 462/518) identified need for specific outpatient programs, 87.3% (n = 452/518) said detoxification units, 85.3% (n = 442/518) indicated outpatient intermediate resources, and 74.5% (n = 386/518) identified specific hospitalization units. Similar perceptions of treatment resource needs were reported by professionals from both the drug addiction and mental health networks. DISCUSSION To our knowledge, this is the first national survey of professionals regarding the availability of specific resources for the management of patients with dual pathology in Spain. Results from the online survey revealed that, while professionals are aware of the need for specific treatment resources for these patients, available integrated health care resources are still scant. Professionals perceptions have helped to understand the causes and consequences of treatment nonadherence (Olivares et al., 2013). Recent studies also highlight the importance of the professionals perceptions on the management of patients with dual diagnosis because they are the ones who actually prescribe and apply the different treatments (Oller-Canet et al., 2011). They detect when a patient is noncompliant (Velligan et al., 2010) and can provide explanations that may help to improve the treatment and management of these patients (Roncero et al., 2013). Professionals support the need for implementing integrated resources for the management dual diagnosis, taking into account the high prevalence, worse prognosis and outcome, and higher rates of morbidity and mortality associated with this condition (Grant et al., 2004; Roncero, Fuste et al., 2011; Roncero, Barral et al., 2011; Swendsen et al., 2010; Szerman, 2013; Daigre et al., 2013). Specialized approaches for dual pathology may address the high incidence of polypharmacy in these patients (Grau-López et al., 2014), although, traditionally mental health and substance misuse services have worked sequentially or in parallel in treating patients with dual diagnosis (Brunette & Mueser, 2006; Roncero, Barral et al., 2011). In our study, only 54.0% of respondents were aware of available integrated resources. While professionals are increasingly more aware of this condition and the need for integrated strategies, integration is only partially implemented and focuses primarily on combined administration of medications and psychotherapy (Green, 2006; Hawkins, 2009; Farren et al., 2012). Furthermore, evidenced-based data on the current health care resources available for the effective management of patients with dual disorders are still scarce. However, currently available scientific evidence supports the notion that co-occurring disorders are ideally best treated within an integrated care setting (Hawkins, 2009; Farren et al., 2012; Pettinati et al., 2013). Among the different needs detected in this study, we also noted a high degree of job instability and employee turnover among professionals working in integrated treatment settings, preventing them from achieving the right training and experience for managing patients with dual pathology. The high turnover rate may be influenced by burnout (Pedrero, Puerta, Lagares, Sáez, & García, 2004; De las Cuevas et al., 2003) and possibly by the nature of the integrated services and the policies and health care planning of these services, which belong either to the addiction treatment network or to mental health services, underlying the high degree of job instability and employee turnover. Indeed, in the absence of coherent long-term planning by health care managers and policy makers, generally highly motivated health care professionals working in such integrated resources often seek a more stable job placement in face of the reorganization of services and the prioritization of other treatment resources. In our study, we also noted a lower frequency of turnover in professionals belonging to both networks or to unified networks (drug addiction plus mental health), thus supporting the benefits of integrating both areas for the most optimal clinical practice. In this study, outpatient treatment programs, as well as outpatient intermediate resources, were purported to be scarce. Outpatient strategies have been proposed as a promising system for the global management of patients with dual pathology, particularly in young patients (Hintz & Mann, 2006; Hawkins, 2009). Proximity and contact with the health care and neighborhood communities are key elements that these patients can find in outpatient resources and that can, in some cases, help 2014, Volume 10, Number 2

6 88 N. Szerman et al. avoid further inpatient interventions. Similarly, we also noted a low presence of specific ancillary interventions, such as vocational or occupational programs. We also noted the scarcity of hospital inpatient units, specifically addressing the needs of patients with dual diagnosis. Based on data on the prevalence of dual pathology reported in previous observational studies (Roncero, Fuste et al., 2011; Arias et al., 2013a, 2013b, 2013c), these specific resources are clearly currently insufficient. Overall, our results highlight the need for significant efforts to implement specific strategies and resources in the management of dual pathology in Spain. To address this situation, we propose that a National Health Plan on dual pathology should be implemented in the near future by the Spanish health authorities, as has been done in other health areas. We also suggest that this issue should be studied from an international perspective that includes the experience of other countries and populations. Although the implementation of integrated and specialized strategies for dual pathology has not been fully evaluated to date, the data presented here strongly support the need to develop integrated services for patients with dual diagnosis. The strengths of this study include the large number of professionals surveyed, the high number of responses by these professionals, and the suitability of the online questionnaires specially designed for the study. There is no official Spanish census of professionals who work in drug addiction (Casas et al., 2009) or in facilities for dual diagnosis (Roncero et al., 2013), so there is no way to determine exact representation of our sample to the larger population of professionals. There are an estimated 900 to 1,000 medical professionals working in the drug addiction network and about 4,500 to 5,000 psychiatrists in Spain, including those in training (Sociedad Española de Psiquiatría, However, it is unknown how many work in facilities that see patients with dual diagnosis. Therefore, we estimate that between 5% and 8% of all the physicians working in the Spanish mental health or addiction network were recruited. Another point that should be mentioned is that no differences depending on the background of the professionals (type of job or network to which they were attached) were observed. Limitations of this study are primarily related to generalizability. It is possible that only self-selected and motivated professionals responded to the survey. Also, the potential bias of over-representation of participants from a given treatment center could not be controlled. Therefore, our results may not be representative of the opinions of all professionals who see patients with dual disorders. In the current context in which providing services for patients with dual pathology represents an important and continued challenge, our results show that professionals strongly believe specific healthcare resources for dual pathology are considerably lacking. Thus, considerable support for the need for additional efforts and strategies for treating individuals with comorbid disorders is evident. ACKNOWLEDGMENTS The study was sponsored by an unrestricted educational grant from BrainPharma, S.A., a subsidiary of Grupo Ferrer, S.A. The authors would like to thank Anna Campuzano, PhD, of BrainPharma, S.A., for technical support for the study development, Núria Piqué for her writing assistance and Grupo Saned, S.A., for technical secretarial services and for the statistical analysis. This study was performed under the auspices of the Spanish Plan Nacional sobre Drogas. The abstract of this study was a poster presentation at the III International Congress on Dual Pathology/disorders (Barcelona, Spain, October 2013). DISCLOSURES All authors report no financial relationships with commercial interests. FUNDING The study has been sponsored by an unrestricted educational grant of BrainPharma, S.A., a subsidiary of Grupo Ferrer, S.A. REFERENCES Adamson, S. J., Todd, F. C., Sellman, J. D., Huriwai, T., & Porter J. (2006). Co-existing psychiatric disorders in a New Zealand outpatients alcohol and other drug clinical population. Australian and New Zealand Journal of Psychiatry, 40(2), doi: /j x Arias, F., Szerman, N., Vega, P., Mesias, B., Basurte, I., Morant, C.,... Babin, F. (2013a). Abuse or dependence on cannabis and other psychiatric disorders. Madrid study on dual pathology prevalence. Actas Espanolas de Psiquiatria, 41(2), doi: /j.rpsm Arias, F., Szerman, N., Vega, P., Mesias, B., Basurte, I., Morant, C.,... Babin, F. (2013b). Alcohol abuse or dependence and other psychiatric disorders. Madrid study on the prevalence of dual pathology, Mental Health and Substance Use. Actas Espanolas de Psiquiatria, 41(2), doi: / Arias, F., Szerman, N., Vega, P., Mesias, B., Basurte, I., Morant, C.,... Babín, F. (2013c). [Madrid study on the prevalence and characteristics of outpatients with dual pathology in community mental health and substance misuse services]. Adicciones, 25(1), Baldacchino, A. (2007). Co-morbid substance misuse and mental health problems: Policy and practice in Scotland. American Journal on Addictions, 16(3), Banerjee, S., Clancy, C., & Crome, I. (2002). Co-existing problems of mental disorder and substance misuse (dual diagnosis): An information manual. London: Royal College of Psychiatrists Research Unit. Brunette, M. F., & Mueser, K. T. (2006). Psychosocial interventions for the long-term management of patients with severe mental illness and cooccurring substance use disorder. Journal of Clinical Psychiatry, 67(7), Casas, M., Arranz, F. J., & Roncero, C. (2009). Grupo de estudio sobre intervenciones clínicas en conductas adictivas: GICCA: Documento de conclusiones. Barcelona: Drug Farma. Journal of Dual Diagnosis

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